When I was a child and knocked a glass off the table, my mother the engineer led me through one of my first failure analyses: a consideration of why and how the glass ended up on the floor along with the milk in it, a model of how, as she said, "Accidents don't happen: they're caused." Not always by a human (though usually) and certainly not always by the person who's hurt. A friend of mine was killed by a tire that came off a large truck going the other way, into oncoming traffic, where it smashed into the windshield of her car and crushed her face into her brain. Her teenage daughter, a front-seat passenger, grabbed the steering wheel and steered the car safely to the side of the road. That was certainly not Sally's fault. But in any situation, my mother's response was to analyse what went wrong so that a similar unwanted event would not happen again. I had set the glass of milk on the edge of the table (easier for me) where it could easily be knocked off the table. I remember, in that and other occasions when I was led through the process of analysis, resenting it. It was an accident...I hadn't meant the glass or plate to fall, I hadn't intended to drop something breakable, I hadn't planned to flunk that test. Those responses, so natural to a child and to many adults, met firm correction from my mother: it wasn't about what I meant to do, what I planned to do, but what I actually did. I learned---not as well as she wished--to think ahead at least two steps, to imagine alternate possibilities, to look for ways things might fail, rather than assume they would not. I was encouraged to consider what to do if they did--to have a Plan B, and also a Plan C, D, E. Did I always do it? No. Did life itself teach me why it was a good idea? Yes.

Which leads us to the curious affair of the Dallas hospital letting an Ebola patient leave the hospital because they didn't realize he might have Ebola, even though he told them he had come from one of the countries known to be suffering an Ebola epidemic. This is, in epidemiological terms, a big-F Failure. How could a major hospital in a major US city that has a very large, international hub airport, make that mistake, a mistake with potentially deadly consequences? That's the topic here--my own analysis, based on my experiences with medical facilities in Texas (albeit not in Dallas, but down along the Border, in San Antonio, Houston, Austin, and smaller communities here and there. I have been reading medical journals for my own enjoyment for over 40 years; I have a degree and some graduate work in biology, so I understand what I'm reading, and I"m familiar with current issues in hospital management.

The situation has been well-reported. An apparently well individual, who passed inspection at both the departing airport and subsequent transfer airports, arrived in Dallas still apparently well...but actually incubating the disease. This is a scenario that has been widely discussed in the medical literature (and in politics, for that matter) for years--that modern air travel makes it possible for someone incubating a dangerous disease to travel by air and arrive in a distant country before showing any signs of illness. Diseases have already been transported that way--measles, for instance, and influenza. In the medical journals and conferences, the possibility is known, and protocols for dealing with it have been discussed and refined.

With regard to Ebola, commentary in the main medical journals, including the possibility--even the likelihood--that a person incubating the disease might arrive in the US by air was mentioned months ago, and as the situation in West Africa got worse, as it became clear that the situation was not at all contained and the case count increased into the hundreds and then thousands, the probability rose ti near certainty. The Centers for Disease Control (CDC) and the National Institutes of Health, due to some procedural failures in their organizations, found themselves unable to respond as quickly to the growing threat as usual, because Congress forced the shutdown of CDC's only laboratory capable of rapid testing and characterization of Ebola virus in clinical samples, and then called in staff for Congressional hearings. Those politicians who distrust science and scientists, CDC's influence in epidemiology and NIH's in biomedical research, and who have insisted on cuts in budgets related to infectious disease, were having a fine time sneering at the only people who knew damn-all about Ebola, but...it's an election year. And yes, I'm both realistic and cynical. So it was almost August before CDC could get untangled from Congressional red tape and back to their real work of informing physicians and hospitals about how to respond to the Ebola situation.

Their commentary was clear; the protocol understandable to me, the non-doctor. The initial symptoms of Ebola were nonspecific--easy to confuse with other common and less dangerous disease. Fever--but not a spectacularly high fever. Headache in some, abdominal pain in others. Ebola had been mistaken in the past for upper respiratory illnesses, flu, malaria, food poisoning, a stomach virus. Therefore, in the case of travelers from the area of the outbreak, anyone with fever and any other symptoms should be immediately isolated and tested for Ebola; all personnel in contact with the patient should wear full protective gear, and any contact with bodily fluids meant isolating the contact with surveillance, including testing, for the full incubation period. Waiting for the characteristic symptoms would be a mistake, and if the person did not have Ebola, no harm was done by a day or two of isolation until the test results came back.

A couple of days after arrival in Dallas, the man from Liberia felt sick--feverish, headachy, abdominal pain--and went to the emergency room at Texas Health Presbyterian Hospital. There he told the staff at intake that he had traveled recently, from Liberia. That information was entered into a computer records. He was not admitted; he was given antibiotics and sent back to where he was staying, because (said the hospital spokesperson--not medical personnel who had contact with him in the ER) his condition did not require admittance and his symptoms were not specific to Ebola. Two days later, much sicker, he returned to the same hospital, where he was admitted and placed in isolation; tests showed that he did indeed have Ebola.

Mere trickles of information about what happened at the hospital on that first visit, that missed opportunity, have emerged: the computer record apparently edited patient travel data in such a way that the medical staff in the ER did not know he had come from Liberia. (The patient's own statement was that he told people at the hospital several times that he had, but it's not clear if he told one person repeatedly or several persons, or whether that was in triage or was said to a medical staffer.) [ [EDITED 10/4 afternoon: The hospital has now changed its story and says the information about travel was available to both doctors and nursing staff. This is not what they said yesterday and the day before. Their new statement was taken from the hospital's own website.]] The identities of the individual who released him, on the first visit, the person who admitted him, on the second, and the person who recognized the possibility of Ebola have not been released, so it is not possible at this time to know their qualifications and experience, or their reasons for the decisions they made, though I'm sure this has been part of the investigation. Nor do we know exactly how or why the computer record was modified so that it did not deliver the travel data to the medical personnel in the ER. This leaves a lot of room for speculation, and only the hospital to discuss in some detail.

Texas Health Presbyterian Hospital, where the patient arrived a few days after his arrival in the United States, is an 898 bed acute-care religious-affiliated nonprofit hospital belonging to a regional association, Texas Health Resources, of such hospitals. When ranked according to the typical criteria for hospitals (ER visits, ER discharges-readmissions, outcome measures for various specific conditions, etc.) THPH ranks about midway in its own association, and a little below the middle for all Dallas area hospitals. It is not a teaching hospital, and ranks well below the large teaching hospitals in Dallas. It's a middling hospital for Texas in general--many are better, many are worse. But it's not where you'd want to go if you had a serious unusual problem, a critical illness that was being seen in that facility for the first time.

This was obvious to me even before I looked up the hospital and its rankings. A first-rank hospital's senior staff, especially the chief of infectious disease, would have been well aware of the progress of the Ebola outbreaks in West Africa, well aware of the hospital's chances of seeing persons from that area, and would have kept on top of current recommendations for handling a sick person who had been in those countries. The possibility would have been discussed with other doctors, with any medical staff who might come into contact with such a person, and the ER's ability to recognize a potential Ebola case would have been assessed and improved. Not just the ER doctors, but the nurses, the aides, and particularly those who did intake--who gathered information from the patients as they arrived. Staff would be reminded repeatedly that anyone arriving from anywhere in West Africa with a fever should be considered a potential Ebola patient. That travel history was vital, and the full information must get to the medical personnel evaluating the patient. They might not have been able to get the entire nursing staff trained in the elaborate safety measures needed to care for an ward full of Ebola patients, but they would almost certainly have given extra training to the team they planned to assign to do it for one patient.

None of that happened at THPH. Ebola was not even suspected at the first visit, despite this person's having typical early symptoms of Ebola and being from one of the outbreak countries.

But there's another clue to this failure, and it's also from the first visit ER record. The patient had fever and reported abdominal pain, and he was given antibiotics without testing for any of the bacterial causes of abdominal pain. The routine administration of antibiotics for abdominal pain and moderate fever is...no longer best practice. Hasn't been for decades. Most stomach/gut upsets are viral in origin. Unless the pattern of the illness suggests one that is bacterial--and research has shown that a specific antibiotic works against that particular bacteria, antibiotics are not given. (Among other things, antibiotics disturb the intestinal flora, resulting in more problems.) Overuse of antibiotics has other consequences and first-rank hospitals and clinicians know that.

So here's a hospital that is not keeping up to date on common things--the person with a fever and abdominal pain--is it any surprise that it's not keeping up on something new, exotic, unexpected. And that brings up another question. Why would a large hospital in a large city, a city with excellent teaching hospitals, not want to catch up, to be better, to be, in fact, excellent? A variety of answers are possible. Perhaps they believed their own website and thought they already were excellent. Perhaps they felt constrained by financial concerns and skimped on education and training because it would cost more. Perhaps they did not believe anyone with Ebola would ever show up in their ER--surely such a person would go to one of the teaching hospitals or a public hospital. Perhaps they felt politically motivated resistance to instructions coming from CDC. It's important to find out what their motivation for lack of preparedness was.

And when the analysis is finished--when it's known exactly who made which decisions that led to the failure to recognize the possibility of Ebola on that first visit--it's then time to figure out how to prevent another such failure. How to motivate all hospitals to make the changes necessary, to take time and money to train nurses and other staff. How to compensate hospitals for the costs involved in treatment. It is doable. It's been done elsewhere, with fewer resources than we have. But to accomplish it--to make every hospital in the nation capable of recognizing and safely caring for an Ebola patient--we must pursue every failure even if it bruises some feelings.

If the patient told someone who was entering data that he was travelling from Liberia then:a) I find it hard to see how that got 'edited' to a different value prior to his being admitted/treated in ER. After all, what motive could there be on the part of the person doing data entry to do that?b) if it did go in as Liberia and he was discharged anyway then I'd suspect someone changing it later to cover their ass as the source of the error. :-(c) if it did go in as Liberia even for a short time, I'd find it interesting that the hospital admission software didn't flag it on to a higher authority. If, as I would imagine is the case, the software is one that is common to many hospitals rather than being individual to that one then I would have thought that the company maintaining would have issued an update that essentially said if travel="dangerous places" and symptoms="any of these" then TELL SOMEONE or DO SOMETHING TO DRAW ATTENTION TO THIS..Given the above I'd begin to wonder if the simpler explanation might be the old one that "everyone lies" and that the patient perhaps did not tell them he'd travelled from Liberia at all!

a) Apparently--and according to a hospital source--the travel data as presented in the record only indicated significant foreign travel if the patient arrived from locations where the flu season is different, so "foreign" flu would be recognized. Who authorized that isn't public knowledge at this point, but I can see how some programmer unfamiliar with medicine or a hospital administrator concerned about their most common disease-of-concern would trying to "simplify" things for ER personnel by giving them a binary answer when a more complex one was needed. Which would be a strong signal that the hospital is not used to receiving patients who have done a lot of foreign travel and may thus appear with diseases acquired abroad. (Most Texas hospitals that size--and many smaller--do see travel-related illnesses, but many affluent patients get to the hospital by way of specialists who've already diagnosed it.)

b) Never underestimate the incompetence of any system in a second-rate operation of any kind (not just hospitals.) It could be that the data were changed later, but I think it more likely that--whether by a systems-design error unknown to or approved by administration--the information was entered on the first visit and did not make it to the persons actually evaluating the patient. Or--worst case--that it did make it to them and was ignored because it was not understood. The details should come out in the ongoing investigation (as nurses' complaints from many quarters indicate that they have not received training they feel is adequate to deal with Ebola in their own hospital setting.)

c) Again...never underestimate incompetence. Not all hospitals use the same software. Did the person choosing the software for this hospital (possibly the entire Texas Health group) have the ability to check deeply into the software and also have a solid knowledge of what was needed for diagnosis of unusual (for this region) diseases? Did anyone programming the software know enough about hospital practice to go beyond providing records required to keep track of patients, their medication, and accounting? Were there locally customizable options, such as 'what do you want flagged in travel history?' with a set of options. Back when I was still involved in medicine, and recently involved in programming, there was some startlingly bad medical-related software on the market...but you had to have some grasp of both programming and medicine to spot it. Once in use, was it modified locally--did someone on that hospital's payroll, at the request of someone else, tinker with the software? (Every user would like custom-tailored software that's exactly right for them--and that includes me, though I don't tinker with the stuff I use now. I just cuss at the programmers in absentia.) The hospital claims it's already modified the software so it won't do that again (if it "did that" in the first place), so if I were one of the investigators I'd make them show my code-savvy assistants the actual code, and I'd try to reproduce the original situation, then reset it to something better.

(c) continued (separate because LJ caps replies at an arbitrary length and then doesn't provide a counter so you can tell when you get close. Speaking of lousy programming decisions.)

I think it really unlikely that the patient lied about having told someone he come from Liberia, for the simple reason that the patient knew Ebola was a possibility--even a probability--and knew that receiving treatment as early as possible was his only hope to survive. He was urban--worked as a limo driver, not a country job. Thus he both saw Ebola and knew the facts about it that many Americans still haven't grasped. It was in his best interests to tell medical personnel as soon as possible--it would be inconceivable to him that here--where supposedly there's "the best medical care in the world" as some of our politicians have it (wrongly)--a hospital would be ignorant of the connection. It's possible (slightly) that his accent was against comprehension (there are varieties of English I find hard to understand because the accents fall on different syllables and are tonally different; vowel sounds also vary. It takes me a little time to reset my brain for New Zealand's English, for instance, but also Indian and Pakistani accents and some African ones. In this country, I found Eastern Shore to be difficult at first.) But once he was sick, he would know he wasn't going to be deported unless he lived through the disease in isolation, because that would put more people at risk...and fear of deportation would be his only reason not to tell the hospital where he'd come from.

Apparently the software doesn't display notes entered by nurses to doctors. Whether that is *all* notes, or just *some* notes wasn't specified (I suspect the latter, but wouldn't be too surprised if it was the former)

From knowing someone here on LJ who is not only a nurse, but *teaches* nursing, I'm sadly not surprised at this.

It's part and parcel of the "nurses are third class citizens" attitude in medicine. They can't *possibly* know anything significant to doctors. :-(

Mind you, there can be legit reasons for nursing notes to be kept away from doctors, as sometimes they contain stuff that probably should be kept from them (including veiled comments about how stupid the doctor is being).

But those notes should not have been classified as "doctor doesn't need to know"

It could be a design error (nurse notes never get seen by doctors). Or it might "merely" be a training error (say, there being a checkbox to make sure the doctor sees the notes and it wasn't checked, or there being a seperate place to enter notes you *want* the doctor to see).

Mind you, even with software written correctly, the training errors can be a royal pain. (I recall when I was getting called in several times a week at 3 am because users couldn't follow instructions on the screen to get data copied to a floppy. And they'd supposedly been walked thru it be their lead before)

I'm also reminded of a long-running discussion on the comp.risks newsgroup/mailing list. The medical field is *very* resistant to having and using (using *properly* anyway) checklists. But far too many errors, *serious* errors could be prevented by using them.

I'd say this is such a situation. Badly implemented "list" in software or failure to use it properly.

I think you're probably right. NEJM has had articles on the difficulty of getting a group or a hospital to change to better practices. And I personally understand the difficulty of learning data entry when systems change and nothing is in the familiar place, sometimes not even called the same thing (looking at you, Microsoft and also Mozilla, which for some insane reason decided to change wording in Thunderbird. If I'm in the newsreader, "Reply" now means "email to sender of post you're reading" and "Followup" means "reply to newsgroup.") Every medical office I've been in in the past ten years I've heard office staff complaining that "the new system" makes their life harder, largely because there's no standardization of the order in which data should be entered (so on older patient records it's here, but in the new system it's there...) or even the format (is Date of Birth M/D/Y or D/M/Y? Is the patient name field long enough? Does it call for Last Name, First Name, Middle Initial, or First Name, Middle Name, Last Name? Or something else? Will the system retrieve a record by patient's name, or do you have to know the patient's file number, or does it retrieve by SSN?

Clerical staff in both doctors' offices and hospitals are overloaded with paperwork, all of it requiring data entry in multiple formats--learning new ones every so often just adds to the load.

I used to write software for the QA dept at the company I worked for. And I made a point of talking to the users about the interface. Still didn't help when leads were too busy to train newbies. :-(

also didn't help when they demanded software do stuff the wrong way (produce reports of properties of a shipment by combining the results of sampling the several production lots that had been used to make it up).

And invariably you train the leads and not only do they not train the newbs, they don't use it themselves.

The last training that I did was to teach basic HTML/CSS to people who would update the public-facing web site. I taught the intro, then the web admin taught the advanced stuff of actually using the CMS system. We had high-level managers and department heads come to the training when there was no way they would ever be using the system.

And now the good news.

The EMS crew who picked the patient up the second time. They were either told (by family or patient) or were alert enough to pick up on the symptoms (then more obvious) and the patient's origin, but they informed the hospital that the patient probably had Ebola. And they were willing to transport him.

I'm sure someone will question why they took him back to the hospital where he had been misdiagnosed before--and I'd like to know the thinking behind that decision myself. Probably the family told them to go to THPH, and typically EMS will transport to the patient/family-specified hospital. At first thought, he should have been taken to one of the best hospitals--a teaching hospital, almost certainly--whose protocols were more up-to-date. But if that hospital was full and had no space for a patient who would require a separate suite (for the prep room and the patient room) that's one reason not to go there. Another is that THPH was already contaminated by his earlier visit--full of people who were going to need to be closely watched and tested--and taking him back there would ensure that attention (life-saving attention) would focus on those people--something that might slip through if the patient himself were elsewhere. Confining the risk is a good idea. But I'm wondering if Dallas EMS already had a protocol in place for this. I'll bet they have one now. If it were MY EMS, I'd specify a particular unit in the metro area as potential high-risk transport, equip the station it's assigned to with the protective gear needed, have CDC conduct life-action training with the crews who ride out on it. Coordination with the best hospital for the case would have been set up, both crew and receiving hospital would know in advance where to go and what to do when the ambulance arrived. That way, when a call came in, the relevant information could be gathered, and this unit sent. Protocols for its subsequent decontamination and the necessary surveillance of its crew would be written out, checked with CDC for completeness, to minimize the chance for exposure and an outbreak.

But a big Yay for the crew, who undoubtedly had insufficient protective gear but didn't run off in a panic.

Re: And now the good news.

As a recently arrived foreign national, I doubt he had any insurance. I don't know that for a fact.

Closest hospital may be a reason, but once you have the penny drop that it's probably Ebola, that's a choice point. It's one that could even override religious preference. (How many Presbyterians are there in Liberia anyway? I dunno.)

Re: And now the good news.

My husband read a different article that said it was an in-law who saw the petechia (signs of bleeding) in his eyes and realized what it might be, and that she called EMS and told them when the arrived she thought he might have Ebola--he'd been in a country with it. They put on protective gear before loading him into the unit.

I suspect, with interviews with different people, several stories will float around, and more than one will be true, but seen from another POV.

On probable factor in the first wrong decision, to send the patient away in that first visit, is one that will be hard to prove though many of us are fairly sure it exists. And that's race. This is a racist society. How one is treated in an emergency room does vary with race and with obvious ability--or inability--to pay for treatment, as well as with the ER's perception of the seriousness of the problem. This patient is African, dark-skinned, speaks with an accent no doubt (though I haven't heard him, of course, I have heard recent African immigrants and students) and is foreign. In an ER focused on the bottom line, this is a liability--someone they would want to get out of their ER, someone they would not risk admitting lest he be a deadbeat. Proving that this had any part in the decision will be next to impossible unless someone lower on the staff plays whistleblower--the hospital's lawyers will have told the spokespersons what to say and how to say it. They know--probably everyone on staff knows--that racism will be suspected and if proven will bring the feds down on them even harder. But Dallas is a very right-wing part of Texas, and I strongly suspect that racism and classism played a part in the decision (and they are now resenting the heck out of what happened next.)

Wow. Another failure point. I'll have to look into that. What did HE do with the information? When did he get the information (while the patient was in house, after the patient had been discharged from the ER, a day and a half later?) What did he do upon receiving the information? (A perfectly natural first reaction would be to think "Oh, SH*T! We're in for it now!" But AFTER that what did he do, and why?) Did he see the patient?

Your tire story was really weird to read, as I'd heard it before. Obviously a lot of people have been killed by that particular type of failure, but I knew I'd heard that story from my wife, and one of my wife's astronomer friends is named Sally, and her parents are both dead. Turns out that it happened to her husband, Ralph. His dad was killed by this failure mode, the passenger was able to steer the car to hit a tree on the driver's side, Ralph was in the back seat.

It would have been super freaky if it had been the same Sally in both our stories.

Re: Texas hospitals, I overheard at the Alamogordo pharmacy yesterday about a worker being tested positive for something and possibly continuing working. Being a mild hypochondriac, something that comes with missing a significant chunk of your immune system, I asked the pharmacist what they were talking about, concerned that it might be local. It wasn't, the story was about a nurse who tested positive for TB. She worked in the baby ward. In Dallas. Possibly in the same hospital as the Ebola patient. Yes, there are lots of hospitals in Dallas, I couldn't get first-hand info on it.

Stuff coming off of traffic going the other way kills a surprising number. One of the ambulance calls I was on, the driver was killed by a small sign trailer (a sign mounted on a small two-wheel trailer) which had been carried on a larger flatbed trailer with other similar signs). It fell off the back (why its restraint came loose I don't know) on a curve and of course kept going in a straight line, which put it crossing the center line...wheels behind, long trailer tongue in front...which bounced off something in the road, entered the driver side window--and by the laws of physics, pivoted on the fulcrum of the window-post, smashing the drive in the back of the head and into the steering column...then fell free as the car was heavier and kept rolling forward. Again, a front-seat passenger (the driver's son) grabbed the wheel and controlled the car until it stopped.

I've had 18-wheeler tires disintegrate, blow out, in front of me, as they passed and then pulled in ahead of me. Big chunks of tire flying back. The big highway I drive on oftenest has put in a divider between lanes that's supposed to prevent tires from getting into oncoming lanes, but it's not high enough (I'm not sure how high would be enough, but I've seen loose tires bounce higher than that.)

Oh--and re: health care workers working while sick/contagious. Many people can't afford to take time off work when they're sick. Which is why everyone needs paid sick leave. If a nurse, however, fails to report a positive TB test and continues to work with patients...the nurse is likely to be found out (not as soon as one could wish) and will face stiff penalties.

Additional software data

According to local news yesterday, several of the hospitals in my city (not Dallas; nowhere even near Texas) have turned up a similar type of software problem with their electronic ER intake forms - there is no place other than "notes" to enter information like "I just got back from Liberia" and no way to flag the notes as "Vitally important; Read This Now" for the next person up the chain. Needless to say, there has been a scramble to find programmers who may be able to fix the problem, as well as additional emergency protocols being put in place (we are assured) to handle such a potential patient when one walks into an ER.

So the computer thing is not just a Dallas hospital problem; it's a problem that may well be endemic to ER hospital software. National news seems still to be concentrating on Dallas, but at least here they're trying to learn from the problem and avoid it.

Re: Additional software data

It's great that they're trying to fix it. In the meantime, there's a simple, inexpensive, non-digital solution. Train the ER intake staff on it.

Have yellow or orange 3x5 cards for them to use, stamped PRIORITY E. When someone comes in admitting a history of recent (within 21 days) presence in Guinea, Sierra Leone, or Liberia, hand the patient one of those cards, attach a second one to a clipboard writing in the , pick up the phone and call the hospital number the hospital has chosen to use, and say "I have a Priority One possible, travel history positive."

The advantage here is that it's fast (every office supply store has yellow 3x5 cards, some have orange as well), cheap, and the color is bright--it will be noticed, if it is used ONLY for serious infectious diseases (and, right now, only for Ebola.) It can be accomplished in however long it takes to get hold of those yellow cards and have someone stamp them with "priority" (a stamp I've seen ready-made in some office supply stores--an probably quickly made anyway) so the clerk can add the E. It does not require physical contact with the patient. (a hand-stamp would be a positive way of IDing the patient but a) is less visible on dark skinned persons and b) requires contact or very close near contact with the patient.) The criteria--within the past 21 days has been in one of those three countries and is sick--can be printed in large letters on a sheet of paper and taped to the desk as a reminder.

One thing that keeps surprising me is how few people are able to recognise potential systemic failures.

I've worked in a number of environments where every problem was addressed individually, and that particular hole fixes, usually after something bad had happened (and all of those incidences were minor) - but any time I've raised a flag of 'hey, we've got several problems all showing the same pattern, can we fix the underlying issue' I've been told 'no'. Too expensive, no need. And so organisations go on to carry systemic problems around, because so far they haven't been catastrophic.

The lesson for computer types (and managers!) is that bad interface design can kill. It's not just about prettyness or convenience; nurses not being able to flag up or identify vital information IS a matter of life or death.

Bad interface design includes frequent changes of interface offered the user as "improvements." Learning new design takes computing power away from anything else the user is doing and increases the chance of error--the more stress the user is under, the longer it takes to learn a new layout. Keep important field where they have been visually; keep command buttons looking the same, and in the same place--don't just decide to move them for the programmer's notion of what looks better.

Especially for people who work on the computer, and whose work needs to be accurate and the output useful for others--when the computer is the tool, not a toy, a diversion, entertainment, or the *subject* of the work--unnecessary changes make them less productive, even when the intention was to increase productivity.